Skip to main content
SpringerLink
Log in

Diagnosis and surgical management of insulinomas in 33 consecutive patients at a single institution

  • ORIGINAL ARTICLE
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Purpose

The purpose of this study was to evaluate the diagnosis and surgical management of insulinomas in a single-center setting.

Methods

Demographic details, clinical presentation, preoperative diagnosis, surgical strategy, and outcomes of 33 consecutive patients who underwent surgery for insulinoma were analyzed retrospectively.

Results

The median time from the first onset of symptoms to diagnosis was 24 months (range 3 days to 50 years). All cases presented with Whipple’s triad and had a fasting insulin to glucose ratio higher than 0.33. The preoperative detection rates of transabdominal ultrasonography, CT, MRI, and EUS were 22 % (2/9), 72 % (23/32), 75 % (9/12), and 80 % (4/5), respectively. Intraoperative manual palpation localized all cases. Enucleation was performed in 58 % of cases (19/33), partial pancreatic resection in 39 % (13/33), and enucleation plus partial resection in 3 % (1/33). Pancreatic fistula was the most common complication and occurred in 15 patients (45 %), including seven grade A, five grade B, and three grade C fistulas. There was no mortality. When compared with partial pancreatectomy, enucleation held a significant advantage in operative time and operative bleeding, with no significant differences in demographic data and postoperative complications. During a median follow-up period of 32 months, two patients were lost to follow-up and the remaining 31 patients were without evidence of recurrence.

Conclusions

A fasting insulin release index larger than 0.3 is a reliable indicator for the diagnosis of insulinoma. Intraoperative palpation by an experienced surgeon can effectively complement an uncertain preoperative localization. Compared with partial pancreatic resection, enucleation showed significant benefit in terms of intraoperative blood loss and operation time.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Service FJ, McMahon MM, O'Brien PC, Ballard DJ (1991) Functioning insulinoma—incidence, recurrence, and long-term survival of patients: a 60-year study. Mayo Clin Proc 66(7):711–719

    Article  CAS  PubMed  Google Scholar 

  2. Boukhman MP, Karam JH, Shaver J, Siperstein AE, Duh QY, Clark OH (1998) Insulinoma—experience from 1950 to 1995. West J Med 169(2):98–104

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Halfdanarson TR, Rubin J, Farnell MB, Grant CS, Petersen GM (2008) Pancreatic endocrine neoplasms: epidemiology and prognosis of pancreatic endocrine tumors. Endocr Relat Cancer 15(2):409–427

    Article  PubMed  PubMed Central  Google Scholar 

  4. Ito T, Igarashi H, Jensen RT (2012) Pancreatic neuroendocrine tumors: clinical features, diagnosis and medical treatment: advances. Best Pract Res Clin Gastroenterol 26(6):737–753

    Article  PubMed  PubMed Central  Google Scholar 

  5. Oberg K, Eriksson B (2005) Endocrine tumours of the pancreas. Best Pract Res Clin Gastroenterol 19(5):753–781

    Article  PubMed  Google Scholar 

  6. Sotoudehmanesh R, Hedayat A, Shirazian N, Shahraeeni S, Ainechi S, Zeinali F, Kolahdoozan S (2007) Endoscopic ultrasonography (EUS) in the localization of insulinoma. Endocrine 31(3):238–241

    Article  CAS  PubMed  Google Scholar 

  7. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula Definition (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13

    Article  PubMed  Google Scholar 

  8. Roth J, Komminoth P, Heitz PU (1995) Topographic abnormalities of proinsulin to insulin conversion in functioning human insulinomas. Comparison of immunoelectron microscopic and clinical data. Am J Pathol 147(2):489–502

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Sharma P, Sharma S, Kalhan S, Singh BP (2014) Insulinoma: a comprehensive summary of two cases. J Clin Diagn Res 8(9):FD05–FD06

    PubMed  PubMed Central  Google Scholar 

  10. Mirancea GV, Morosanu AM, Carniciu S, Dima S, Bacalbasa N, Popescu I, Ionescu-Tirgoviste C, Mirancea N (2014) Relevant infrastructural alterations in a pancreatic neuroendocrine tumor: an insulinoma case. Romanian J Morphol Embryol 55(2 Suppl):659–668

    Google Scholar 

  11. Ielpo B, Caruso R, Ferri V, Quijano Y, Duran H, Diaz E, Fabra I, Puga R, Oliva C, Olivares S, Vicente E (2013) Giant pancreatic insulinoma. The bigger the worse? Report of two cases and literature review. Int J Surg Case Rep 4(3):265–268

    Article  PubMed  Google Scholar 

  12. Bright E, Garcea G, Ong SL, Madira W, Berry DP, Dennison AR (2008) An unusual case of concurrent insulinoma and nesidioblastosis. JOP 9(5):649–653

    PubMed  Google Scholar 

  13. Tongson-Ignacio JE, Honda SA, Bhagavan NV (2005) Insulinoma, a rare neuroendocrine tumor: a case report. Hawaii Med J 64(1):9–11

    PubMed  Google Scholar 

  14. Mittendorf EA, Liu YC, McHenry CR (2005) Giant insulinoma: case report and review of the literature. J Clin Endocrinol Metab 90(1):575–580

    Article  CAS  PubMed  Google Scholar 

  15. Roland CL, Lo CY, Miller BS, Holt S, Nwariaku FE (2008) Surgical approach and perioperative complications determine short-term outcomes in patients with insulinoma: results of a bi-institutional study. Ann Surg Oncol 15(12):3532–3537

    Article  PubMed  Google Scholar 

  16. Zhan HX, Cong L, Zhao YP, Zhang TP, Chen G (2013) Risk factors for the occurrence of insulinoma: a case-control study. Hepatobiliary Pancreat Dis Int 12(3):324–328

    Article  PubMed  Google Scholar 

  17. Zhao YP, Zhan HX, Cong L, Zhang TP, Liao Q, Dai MH, Cai LX, Zhu Y (2012) Risk factors for postoperative pancreatic fistula in patients with insulinomas: analysis of 292 consecutive cases. Hepatobiliary Pancreat Dis Int 11(1):102–106

    Article  PubMed  Google Scholar 

  18. Horvath E, Gozar H, Chira L, Dunca I, Kiss E, Pavai Z (2013) Insulinoma diagnosed as drug-refractory epilepsy in an adolescent boy: a case report. Romanian J Morphol Embryol 54(4):1147–1151

    Google Scholar 

  19. Louda F, Chadli A, Elaziz S, Elghomari H, Farouqi A (2013) Malignant insulinoma misdiagnosed and treated as epilepsy. Ann Endocrinol (Paris) 74(1):53–55

    Article  Google Scholar 

  20. Correia P, Panchani R, Ranjan R, Agrawal C (2012) Insulinoma presenting as refractory seizure disorder. F1000Res 1:15

    PubMed  PubMed Central  Google Scholar 

  21. Bonato FT, Coelho JC, Petruzzielo A, Matias JE, Ferreira GA (2012) Surgical treatment of pancreatic insulinomas. Arq Bras Cir Dig 25(2):101–104

    Article  PubMed  Google Scholar 

  22. Graves TD, Gandhi S, Smith SJ, Sisodiya SM, Conway GS (2004) Misdiagnosis of seizures: insulinoma presenting as adult-onset seizure disorder. J Neurol Neurosurg Psychiatry 75(8):1091–1092

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Goh BK, Ooi LL, Cheow PC, Tan YM, Ong HS, Chung YF, Chow PK, Wong WK, Soo KC (2009) Accurate preoperative localization of insulinomas avoids the need for blind resection and reoperation: analysis of a single institution experience with 17 surgically treated tumors over 19 years. J Gastrointest Sur 13:1071–1077

    Article  Google Scholar 

  24. Lo CY, Lam KY, Kung AW, Lam KS, Tung PH, Fan ST (1997) Pancreatic insulinomas. A 15-year experience. Arch Surg 132:926–930

    Article  CAS  PubMed  Google Scholar 

  25. McAuley G, Delaney H, Colville J, Lyburn I, Worsley D, Govender P, Torreggiani WC (2005) Multimodality preoperative imaging of pancreatic insulinomas. Clin Radiol 60(10):1039–1050

    Article  CAS  PubMed  Google Scholar 

  26. Anakal MG, Kalra P, Dharmalingam M, Indushekhar S, Rao V, Prasanna Kumar KM (2014) Insulinoma case series: experience of a tertiary care center. Indian J Endocrinol Metab 18(6):858–862

    Article  PubMed  PubMed Central  Google Scholar 

  27. Callacondo D, Arenas JL, Ganoza AJ, Rojas-Camayo J, Quesada-Olarte J, Robledo H (2013) Giant insulinoma: a report of 3 cases and review of the literature. Pancreas 42(8):1323–1332

    Article  PubMed  Google Scholar 

  28. Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Ito S, Ogawa Y, Kobayashi M, Hanazaki K (2013) Diagnosis and management of insulinoma. World J Gastroenterol 19(6):829–837

    Article  PubMed  PubMed Central  Google Scholar 

  29. Mehrabi A, Fischer L, Hafezi M, Dirlewanger A, Grenacher L, Diener MK, Fonouni H, Golriz M, Garoussi C, Fard N, Rahbari NN, Werner J, Buchler MWA (2014) Systematic review of localization, surgical treatment options, and outcome of insulinoma. Pancreas 43(5):675–686

    Article  PubMed  Google Scholar 

  30. Ayav A, Bresler L, Brunaud L, Boissel P (2005) Laparoscopic approach for solitary insulinoma: a multicentre study. Langenbeck’s Arch Surg 390(2):134–140

    Article  CAS  Google Scholar 

  31. Zhao YP, Zhan HX, Zhang TP, Cong L, Dai MH, Liao Q, Cai LX (2011) Surgical management of patients with insulinomas: result of 292 cases in a single institution. J Surg Oncol 103(2):169–174

    Article  PubMed  Google Scholar 

  32. Balci NC, Semelka RC (2001) Radiologic features of cystic, endocrine and other pancreatic neoplasms. Eur J Radiol 38(2):113–119

    Article  CAS  PubMed  Google Scholar 

  33. Vinik AI, Delbridge L, Moattari R, Cho K, Thompson N (1991) Transhepatic portal vein catheterization for localization of insulinomas: a ten-year experience. Surgery 109(1):1–11 discussion 111

    CAS  PubMed  Google Scholar 

  34. Hackert T, Hinz U, Fritz S, Strobel O, Schneider L, Hartwig W, Buchler MW, Werner J (2011) Enucleation in pancreatic surgery: indications, technique, and outcome compared to standard pancreatic resections. Langenbeck’s Arch Surg 396(8):1197–1203

    Article  Google Scholar 

  35. Grygiel K, Szmidt J, Jelenska M, Pawlak K (2012) Surgical treatment of hyperinsulinism during the course of pancreatic cancer (insulinoma) —one center experience. Pol Przegl Chir 84(1):31–36

    PubMed  Google Scholar 

  36. Falconi M, Bettini R, Boninsegna L, Crippa S, Butturini G, Pederzoli P (2006) Surgical strategy in the treatment of pancreatic neuroendocrine tumors. JOP 7(1):150–156

    PubMed  Google Scholar 

  37. Jensen RT, Berna MJ, Bingham DB, Norton JA (2008) Inherited pancreatic endocrine tumor syndromes: advances in molecular pathogenesis, diagnosis, management, and controversies. Cancer 113(7 Suppl):1807–1843

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

This work was supported by grants from the National Nature Science Foundation of China (No.81272239, No.30972912) and the research Special Fund for Public Welfare Industry of Health of China (201202007). The authors gratefully acknowledge Dr. Jorg Kleeff and Dr. Tianshen Hu for revising the language of the manuscript.

Authors’ contributions

Study conception and design: Wei, Miao

Acquisition of data: Wei, Liu, Xu, Zhang

Analysis and interpretation of data: Wei, Liu, Wu, Gao, Jiang, Zhang, Miao

Drafting of manuscript: Wei, Liu, Wu, Xu

Critical revision of manuscript: Wu, Gao, Jiang, Miao

Author information

Authors and Affiliations

  1. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, China

    Jishu Wei, Xinchun Liu, Junli Wu, Wenbin Xu, Wentao Gao, Kuirong Jiang & Yi Miao

  2. Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

    Zhihong Zhang

Authors
  1. Jishu Wei
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xinchun Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Junli Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wenbin Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wentao Gao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kuirong Jiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Zhihong Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yi Miao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yi Miao.

Ethics declarations

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki Declaration and its later amendments.

Informed consent

For this type of study, formal consent is not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wei, J., Liu, X., Wu, J. et al. Diagnosis and surgical management of insulinomas in 33 consecutive patients at a single institution. Langenbecks Arch Surg 401, 1019–1025 (2016). https://doi.org/10.1007/s00423-016-1496-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-016-1496-y

Keywords

Search

Navigation